Motivating Smoking Cessation: Recognizing and Capitalizing on Teachable Moments Belinda Borrelli, PhD Professor & Director, The Miriam Hospital and Brown Medical School, Program in Nicotine and Tobacco
Motivation I have too much stress in my life right now to think about quitting smoking. I smoke outside so I am not hurting my kids My grandfather smoked until he was 95 and he was healthy for all of those years.
Troubleshoot barriers to quitting Help smoker to problem solve and anticipate challenges Measure initiation and maintenance of quitting smoking Adopted from Rosen, Ryan, & Rigsby (2002). Behavior change, 19(4), 183-190 l Relapse due to side effects, psychosocial issues, etc.
Troubleshoot barriers to quitting Elicit motivation to accept tx Help smoker problem solve and anticipate challenges Measure initiation and maintenance of quitting smoking Adopted from Rosen, Ryan, & Rigsby (2002). Behavior change, 19(4), 183-190 Relapse due to side effects, psychosocial issues, etc.
Troubleshoot barriers to quitting Elicit motivation to quit Elicit motivation to accept tx Help smoker problem solve and anticipate challenges Measure initiation and maintenance of quitting smoking Adopted from Rosen, Ryan, & Rigsby (2002). Behavior change, 19(4), 183-190 Relapse due to side effects, psychosocial issues, etc.
Percent of Smokers Motivated to Quit in RI 1 2 3 4 5 6 7 8 9 10 Not at all Somewhat Very Motivated Motivated Motivated Velicer et al., 1995
Patient Centered Approaches to Smoking Cessation Motivational Interviewing What are the patient s concerns, perspectives and myths/beliefs about the smoking? Create comfortable atmosphere so exploration of conflicts about change can be explored. Ambivalence is natural Explores reasons for and against change Designed to enhance intrinsic motivation Emphasize that change is their choice
How to decrease motivation to quit. Confronting Taking Sides Acting as Expert Labeling Warning Persuading Lecturing Providing solutionss Premature Focus l
Assess Motivation Level On a scale of 1-10, how motivated are you to quit smoking right now? What makes you not a 1 or a 2? What will it take for you to get up to an 8 or 9? What would it take to make you more motivated? 1 2 3 4 5 6 7 8 9 10 Not at all Somewhat Very Motivated Motivated Motivated Belinda Borrelli, Ph.D., Brown Medical School & The Miriam Hospital
Assess Confidence Level On a scale of 1-10, how confident are you that you can quit smoking right now? What makes you not a 1 or a 2? What will it take for you to get up to an 8 or 9? What would it take to make you more confident? 1 2 3 4 5 6 7 8 9 10 Not at all Somewhat Very Confident Confident Confident Belinda Borrelli, Ph.D., Brown Medical School & The Miriam Hospital
Help With Decision Making Pros of Smoking Relieves stress Improves mood Habit Something to do with hands Social Cons of Smoking Cough Easily winded Costs $1,300- $1,500/yr Exposure to kids Wrinkles Social outcast No where to smoke Smells
Provide Health Feedback Elicit permission: Would you like to know more about the effects of smoking on your medical condition? What connection, if any, do you see between smoking and your illness? Provide feedback in a non-threatening, neutral manner: Your health condition is sometimes linked to (or caused by) smoking. What happens to some people is that Elicit the person s interpretation. I wonder if we can talk briefly about whether or not this may apply to you? How might continued smoking further impact your illness? How might quitting smoking help your health?
DEARS: Develop a Discrepancy When a behavior is seen to be conflicting with important goals or values, change is more likely to occur. Step 1: What is most important to the person (value, goal, hobby) Step 2: Explore the reasons for choice Step 3: Develop discrepancy. How does continuing to smoke move you closer to getting x? How does continuing to smoke move you further from getting x? What do you make of this difference? ospital
Evidenced-Based Treatments Meta-analyses, 2008 Clinical Practice Guidelines Monotherapies Abstinence rate at 6 months Nicotine Patch 23.4% (>25 mg = 26.5%) Nicotine Gum 19.0% Nicotine Lozenge ------ Nicotine Inhaler 24.8% Nicotine Spray 26.7% Bupropion 24.2% Varenicline 33.2% (2 mg), 25.4% (1 mg) Combination Therapies -Patch > 14 weeks + ad lib NRT = 36.5% -Patch + Bupropion = 28.9% B. Borrelli, Ph.D
Evidenced-Based Treatments Meta-analysis, 2008 Clinical Practice Guidelines Behavioral Tx Intra-tx social support 14.4% Extra-tx social support 16.2% Counseling/problem solving 16.2% Quitline 12.7% Combination Abstinence rate at 6 months Medication and Counseling 27.6% -32.5% Medication and Quitline 28.1% Medication (alone) 23.2% B. Borrelli, Ph.D
We need to increase use of Evidenced-Based Treatments Only 20-30% of smokers use EBTs to quit (Cokkinides et al 2005) Only 6% use a combo of meds and counseling to quit (Shiffman et al. 2008) 342 state medicaid programs and 96% of US health plans provide coverage for EBTs (CDC, 2006). Minority and low income smokers are less likely to use NRT or d/c use prematurely (Borrelli et al; Fu et al 2005). B. Borrelli, Ph.D
Concluding Thoughts Match counseling to person s level/stage of motivation to quit. Reframe past quit attempts as learning experiences vs. failures. Ambivalence is normal; don t fight against it. Motivate people to use evidenced-based treatments. B. Borrelli, Ph.D